Transcatheter Aortic Valve Replacement in Degenerated Perceval Bioprosthesis: Clinical and Technical Aspects in 32 Cases.

BACKGROUND: Sutureless aortic bioprostheses are increasingly being used to provide shorter cross-clamp time and facilitate minimally invasive aortic valve replacement. As the use of sutureless valves has increased over the past decade, we begin to encounter their degeneration. We describe clinical outcomes and technical aspects in patients with degenerated sutureless Perceval (CorCym, Italy) aortic bioprosthesis treated with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). METHODS: Between March 2011 and March 2023, 1310 patients underwent aortic valve replacement (AVR) with Perceval bioprosthesis implantation. Severe bioprosthesis degeneration treated with VIV-TAVR occurred in 32 patients with a mean of 6.4 ± 1.9 years (range: 2-10 years) after first implantation. Mean EuroSCORE II was 9.5 ± 6.4% (range: 1.9-35.1%). RESULTS: Thirty of thirty-two (94%) VIV-TAVR were performed via transfemoral and two (6%) via transapical approach. Vascular complications occurred in two patients (6%), and mean hospital stay was 4.6 ± 2.4 days. At mean follow-up of 16.7 ± 15.2 months (range: 1-50 months), survival was 100%, and mean transvalvular pressure gradient was 18.7 ± 5.3 mmHg. CONCLUSION: VIV-TAVR is a useful option for degenerated Perceval and appears safe and effective. This procedure is associated with good clinical results and excellent hemodynamic performance in our largest single-center experience.

Peripheral intravascular lithotripsy for transcatheter aortic valve implantation: a multicentre observational study.

BACKGROUND: The presence of severe calcific atherosclerosis at the iliofemoral axis may preclude transcatheter aortic valve implantation (TAVI) by the transfemoral (TF) approach. Intravascular lithotripsy (IVL) is a novel technology that fractures intimal/medial calcium and increases vessel compliance allowing TF TAVI in selected patients with peripheral artery disease (PAD). AIMS: The aim of this study was to report on the safety and efficacy of IVL-assisted TF TAVI in an all-comers population. METHODS: Clinical, imaging and procedural data on all consecutive patients treated by IVL-assisted TF TAVI in six high-volume European centres (2018-2020) were collected in this prospective, real-world, multicentre registry. RESULTS: IVL-assisted TF TAVI was performed in 108 patients, increasing from 2.4% to 6.5% of all TAVI from 2018 to 2020, respectively. The target lesion was most often localised at the common and/or external iliac artery (93.5% of cases; average TL-MLD 4.6±0.9 mm with 318 degrees of calcium arc). Transfemoral aortic valve delivery was successful in 100% of cases; final procedural success in 98.2% (two conversions to cardiac open surgery for annular rupture and valve migration). Complications of the IVL-treated segments consisted of 1 perforation and 3 major dissections requiring stent implantation (2 covered stents and 2 BMS). Access-site-related complications included 3 major bleedings. Three in-hospital deaths were recorded (2.8%, 1 failed surgical conversion after annular rupture, 1 cardiac arrest after initial valvuloplasty, 1 late hyperkalaemia in renal dysfunction). CONCLUSIONS: IVL-assisted TF TAVI proved to be a safe and effective approach, which helps to expand the indications for TF TAVI in patients with severe calcific PAD. However, these patients continue to have a higher-than-average incidence of periprocedural complications.

Clinical characteristics and outcomes of Yemeni patients with acute heart failure aged 50years or younger: Data from Gulf Acute Heart Failure Registry (Gulf CARE).

AIMS: There is a shortage of data about acute heart failure (AHF) in the young, including its underlying causes, clinical presentation and outcomes. We aim to describe clinical characteristics, causes and outcomes of AHF in Yemeni patients aged 50years or younger. METHODS AND RESULTS: we evaluated Yemeni patients with AHF enrolled in Gulf CARE registry. Patients were divided into two groups: young patients (≤50years) and older patients (>50years). A total of 1536 patients with AHF were enrolled, of whom 635 (41.3%) were 50years old or younger. The mean age for this group was 38.8 (±9.5) years; and 399 (62.8%) were males. Younger patients had a higher prevalence of non-ischemic cardiomyopathy (41% vs 11.1%, p<0.001), primary valvular disease (27.9% vs 3.2%, p<0.001), viral myocarditis (0.8% vs 0, p<0.001). Ischemic heart disease (61.6% vs 25.5%, p<0.001) and hypertensive heart disease (18.3% vs 6.3%, p<0.001) were more frequent in the elderly group. Cardiogenic shock was more frequent among younger patients (13.7% vs 7.0, p<0.001). In-hospital mortality was higher in patient aged ≤50years (12% vs 7.6%, p=0.002) while no difference in all-cause mortality was present at 3months (17.8 vs 14.5, p=0.089) and after 1year (21.9% vs 20.6%, p=0.56). CONCLUSION: This analysis of Gulf CARE registry represents the largest report of patients admitted with AHF in Yemen. There were differences among cause of HF and precipitating factors of AHF among younger and elderly patients. Younger patients had higher in-hospital mortality and more severe clinical condition at admission.

Endovascular treatment of acute thoracic aortic syndromes with a proximal landing zone extension strategy: procedural and follow-up results.

PURPOSE: To report the procedural and long-term follow-up data (mean, 43 ± 29 months; range, 12-90 months) of endovascular stent grafting (ESG) of acute thoracic aortic syndromes (ATAS) with a proximal landing zone extension strategy. METHODS: From November 1999 to May 2008, 26 patients (25 males, 1 female; mean age, 57.9 ± 17 years) with ATAS underwent ESG at our institution. Underlying pathologies were: penetrating aortic ulcer (n=7); rupture of a descending aorta aneurysm (n=5), post-traumatic false aneurysm (n=5); acute type B dissection (n=6) and traumatic descending aorta transection (n=3). RESULTS: ESG was performed successfully in all patients. In 5 patients (19%), an extra-anatomic revascularization of the supra-aortic vessels was performed. In 19 patients (73%), overstenting of the left subclavian artery, without preliminary revascularization, was performed. The mean proximal landing zone length was 57 ± 19 mm. No intraprocedural deaths occurred; 3 patients died postoperatively (1 from an unrelated cause, 1 from a myocardial infarction and 1 for the sequelae of an ischemic stroke). One patient underwent cardiac surgery for post-procedural retrograde type-A dissection. Follow up involved a computed tomography (CT) scan at 1, 3, 6 and 12 months, then yearly thereafter. At follow up, no deaths or major complications occurred. The CT scans revealed 1 small type-IB endoleak at 1 year. CONCLUSION: In ATAS patients treated with ESG, the extension of the proximal landing zone, despite the need of subclavian coverage or hybrid procedures, is associated with an immediate procedural outcome and low morbidity at follow-up.

An increased platelet-leukocytes interaction at the culprit site of coronary artery occlusion in acute myocardial infarction: a pathogenic role for "no-reflow" phenomenon?

BACKGROUND: Distal protection devices have been shown to reduce the incidence of "no flow" phenomenon during primary percutaneous coronary intervention (PCI). So far, it has not been well clarified which mechanism is mainly involved in distal coronary protection. AIM: To investigate the activation state of leukocytes and platelets locally present within the blood from the site of coronary occlusion. METHODS: Ten patients with acute myocardial infarction (AMI) underwent primary PCI with an embolization protection device and aspiration catheter (PercuSurge GuardWire) were included. The following functional parameters: a) monocyte and neutrophils surface molecules; b) platelet surface activatory antigens; c) leukocytes-platelet conjugates were studied by flow cytometry in blood obtained from the site of coronary occlusion and from peripheral femoral artery. RESULTS: The leukocyte-platelet adhesion index was significantly higher in the aspirated blood at the site of coronary occlusion than in the peripheral arterial blood for both monocytes (0.226+/-0.04 vs. 0.084+/-0.01; p=0.004) and neutrophils (1.372+/-0.3 vs. 0.524+/-0.1; p=0.02). Moreover, the volume of coaggregates exhibited a significant increase in coronary blood for both populations (p=0.02 for monocytes and for neutrophils). Interestingly, a significant up-regulation of the adhesive molecule CD18 was observed in coronary blood respect to systemic circulation either in monocytes (p=0.01) than in neutrophils (p=0.003). A significant up-regulation of monocyte (HLA-DR) and neutrophil (CD66b) activatory molecules expression was also observed in the aspirated coronary compared to peripheral artery blood (p=0.02 and p=0.03 for HLA-DR and CD66b, respectively). CONCLUSIONS: These data indicate an increased leukocyte-platelet functional interaction in AMI at the site of plaque rupture relative to the systemic circulation, which may be one of the pathogenetic mechanisms responsible for myocardial "no-reflow" phenomenon.

Detection of mtDNA with 4977 bp deletion in blood cells and atherosclerotic lesions of patients with coronary artery disease.

Recent evidence suggests that somatic mutations in nuclear and mitochondrial DNA accumulated during aging, may significantly contribute to the pathogenesis of chronic-degenerative illness such as coronary artery disease (CAD). Mitochondrial DNA with 4977 bp deletion mutation (mtDNA4977) is a common type of mtDNA alteration in humans. However, little attempt has been made to detect the presence of mtDNA4977 deletion in cells and tissues of cardiovascular patients. This study investigated the presence of mtDNA4977 in blood samples of 65 cardiovascular patients and 23 atherosclerotic plaques of human coronaries with severe atherosclerosis. Moreover, the presence of the deletion has been investigated in blood cells from 22 healthy age-matched subjects. The detection of mtDNA4977 has been performed by using a nested polymerase chain reaction (PCR) protocol and normalized to wild-type mtDNA. A significant higher incidence of mtDNA4977 was observed in CAD patients with respect to healthy subjects (26.2% versus 4.5%; P=0.03). Furthermore, the relative amount of the deletion was significantly higher in the patients compared to the control group (P=0.02). The mtDNA4977 was detected in 17 of the 65 patients blood samples (26.2%) and deletion levels ranged from 0.18 to 0.46% of the total mtDNA (mean: 0.34+/-0.02%). For what concerns atherosclerotic lesions, 5 patients (21.7%) showed the deletion ranging from 0.13 to 0.45% of the total mtDNA (mean: 0.35+/-0.06%). In both samples from patients, the incidence and the relative amount of mtDNA4977 was not significantly influenced by atherogenic risk factors and clinical parameters. The obtained results may suggest that the increase of oxidative stress in cardiovascular disease may be responsible for the accumulation of mtDNA damage in coronary artery disease patients.